December 29, 2014 | Government Health IT Staff
Inpatient Electronic Health Records (EHRs) are not optimized to support delivery of quality and safety initiatives and, as a result, providers must be prepared to devote time and effort to continually modify them as they are implemented.
That’s according to a new study published in Electronic Data Methods for which researchers monitored the use of an EHR at three hospitals within Baylor Scott & White Health (BSWH), the largest not-for-profit health care system in Texas and one of the largest systems in the U.S. The researchers focused on treatment of delirium, a common problem for ICU patients addressed through the care processes of daily awakening and breathing trials, formal delirium screening, and early mobility — collectively known as the “ABCDE bundle.”
The study showed that, to effectively use the EHR, the hospitals’ health care delivery system had to modify its inpatient EHR to accelerate the implementation and evaluation of ABCDE bundle deployment as a safety and quality initiative. The researchers worked with clinical and technical experts, including doctors, nurses and support staff at the hospitals to create structured data fields for documentation and to identify where these fields should be placed within the EHR to streamline staff workflow.
They found that modifying the EHRs to support ABCDE bundle deployment was a “complex and time-consuming process,” the researchers wrote. “These shortcomings prevented the delivery of efficient care and our ability to assess the potential benefits of this quality improvement initiative.”
The EHR was not structured in a manner “that facilitated interdisciplinary care coordination among the range of providers in the ICU including nurses, physicians, and respiratory, physical, and occupational therapists,” the researchers wrote. The EHR also failed to allow for documentation of patient eligibility for processes of care in the ICU, such as those contained in the ABCDE bundle, the report said.
The health workers were able to customize the EHR documentation fields to support of ABCDE bundle deployment by assembling a team of IT personnel and clinical experts to identify the bundle data elements to be added to the EHR, to streamline EHR documentation in support of staff workflow, and to make these data accessible to providers. A tab in the EHR Patient Viewer was created to allow clinicians to view in one place the performance of bundle for individual patients.
The researchers said the difficulties in adapting to the EHR in the case study “are generalizable to other healthcare settings and conditions.”
“Tailoring the EHR to accelerate adoption of the ABCDE bundle was a challenging, time-consuming, and resource-intensive process, but we learned many valuable lessons that can facilitate the implementation of future quality improvement projects involving EHR modifications,” the researchers wrote.
They cited the need to gain buy-in from senior leadership at the beginning of the project as crucial to ensure that EHR modifications can be prioritized and resourced properly. With competing demands for time, health systems need to set timeline expectations and provide ongoing training to staff on proper use of the new EHR documentation fields.
The researchers said health care systems are currently challenged to find efficient ways to modify the EHR, and successful implementation is currently dependent on an ability to modify EHRs to meet emerging care delivery and quality improvement needs.
“Many out-of-the-box EHRs are poorly designed for the delivery of clinical care and often do not include good documentation templates and decision-support tools for specific conditions,” the report concluded. “Continual modification and optimization of these systems is needed to meet the needs of providers and, more importantly, of the patients.”